Key themes included: (1) diverse beauty standards across groups, (2) lack of acknowledgement of racialized beauty standards and cultural appropriation, (3) culturally-specific impacts of standards, (4) harm of appearance-related comments, (5) resource limitations, (6) mental health stigma/minimization, (7) inclusive programming barriers, and (8) inclusive programming facilitators. Themes are described below. Quotations include a prefix of W (White), B (Black), or L (Latinx) indicating race/ethnicity, group number, and letter delineating participant.
Diverse Beauty Standards
Groups began by exploring beauty ideals specific to participants’ racial and ethnic backgrounds, and perceived differences among groups. White women overwhelmingly described thinness, exemplified by a small frame, thin waist, and overall slender shape, as the ideal within their race. White participants highlighted a, “flat stomach,” [W1a], “prominent collarbones,” [W1c], and a “thigh gap,” [W1b], as important. White women also expressed awareness of differences between their racial group's beauty standards and those of others, “If you are White, then like, you have to be more [sic] thinner,” [W1e]. Some White women mentioned that standards are, “expanding a little bit…” [W2b]; White women noted that curves are coveted within the context of thinness, stating, “You have to be thin, but have curves” [W1b].
In all Black and Latinx groups, negative connotations of thinness were noted. “Being skinny…like, that’s a bad thing” [B3b]. Similarly, multiple Latinx participants described thinness as undesirable. “In my family and culture, if you’re too skinny, it’s not okay…[then]…they’re like,…’you’re sick’” [L2b]. Many Black and Latinx women identified the, “curvy ideal” as the beauty standard within their culture.
Furthermore, women of color repeatedly highlighted the importance of non-weight related aspects of appearance. Latinx women described feeling pressure to, “make sure you look presentable every day” [L1c], and to have tan, clear skin and long, dark hair. Black women similarly noted that skin tone and hair are important elements of beauty within their race. Participants described, “having your hair put together” as essential to attractiveness. Overall, Black and Latinx participants highlighted the need to incorporate non-weight related appearance pressures into prevention.
Racialized Beauty Standards and Cultural Appropriation
Women of color expressed a desire for programs to acknowledge systemic racism’s influence on appearance standards. Black women noted that, within their culture, lighter skin is considered more attractive than darker skin. Participants expressed frustration with this standard and referred to it as, “racism in our own culture” [B3a]. Multiple women also described experiencing appearance-related racial microaggressions. For example, one Black woman reported hearing others describe someone as, “pretty for a dark-skinned girl” [B4c]. Participants also highlighted the impact of cultural appropriation. They noted that Afrocentric features (e.g., full lips) are considered beautiful on Whites, but devalued among Black individuals. “Since it is common on us, it’s like they don’t care anymore” [B3f].
Women across groups also noted that it remains important to retain some content highlighting society’s idealization of thinness. Indeed, women of color described the importance of acknowledging the effects of dual appearance pressures on body image. For example, Latinx women noted feeling torn between White and Latinx appearance ideals, and described their body image as complicated, because they were, “not looking like [their] sorority sisters” [L1a].
Culturally-Specific Impacts
Black and Latinx participants discussed challenges of meeting both White beauty standards and the (often contradictory) standards within their cultural groups, and described these discrepancies as, “crushing” to their self-esteem [B3f]. Furthermore, women described health risks associated with attempts to obtain appearance ideals, including the use of, “flat tummy teas” that “put [a friend] in the hospital” [B3e]. Participants recommended that programs acknowledge the harms associated with these efforts to conform to beauty ideals relevant to their racial or ethnic identities.
Harm of Appearance-Related Comments
Women across groups repeatedly discussed the negative impact of appearance-related comments on their (and others’) body image (e.g., “I’m so fat,” [W2a, B3c, & L1b] “She’s gotten really fat” [L2a]). Participants emphasized the need for education about the consequences of these comments (e.g., body dissatisfaction), and training in how to respond (e.g., challenging negative self-talk).
Resource Limitations
Across groups, women repeatedly highlighted the need for resources challenging misconceptions about EDs in women of color. They expressed the belief EDs are, “not much of a big thing that you would see in most Latin cultures” [L1c] and “not a Black thing” [B2c]. White individuals reported believing that they are more prone to EDs than Black and Latinx women, because resources disproportionately, “talk about EDs with White women” [W2a].
Groups also provided feedback on a DBI excerpt. Black and Latinx participants reported difficulty relating to the individual described in the role-plays, “I don’t hear our race,” [B2b], and, “Is anyone Hispanic in that scenario?” [L1a]. One White woman also commented on the lack of representation, “I didn’t even realize when you were reading these things that nowhere in these like role-plays is the girl described…Yet,…I was picturing a White girl”[W2d].
Latinx women further indicated that, in general, ED prevention excludes diverse women, highlighting the limited, “resources we can identify with” [L1d]. Black women similarly noted, “Most of the time, when I hear about anorexia, it’s not about Black people…” [B1b] Consequently, Black and Latinx women agreed that they do not think of women within their cultural groups as susceptible to EDs. Participants expressed the importance of all women being, “aware of what can happen to them, and not just like White people, everyone” [L2c].
Stigma/Minimization of Mental Health
In addition to discussing recommendations for culturally adapting programs, Black and Latinx women highlighted the stigmatization and minimization of mental health within their cultures. They commented that mental health concerns are, “not considered real problems” [B2c] within their cultural groups. Further, Latinx women expressed reluctance to seek help for fear of generating, “extra stigmas” [L1a].
Inclusive Programming Barriers
Discussion of barriers to inclusive programming highlighted: stereotypes, vulnerability, diversity, and time. Women across groups noted that stereotypes are incompatible with culturally sensitive programming, commenting, “We should not be shaming cultures,” [W1c]. Participants also expressed concern regarding what others might think about their engagement in a program addressing EDs and weight management, as it demonstrates vulnerability.
Further, women across groups highlighted distinct beauty standards as an inclusive programming challenge. “If you specify one [beauty ideal], someone might think, ‘Oh, that is not how I see it,’” [L1c]. More generally, participants highlighted challenges relating to individuals from disparate backgrounds. Participants agreed, “It’s easier to talk [in homogenous groups] because you feel like you can relate more to the people around you” [B3d]. Latinx women also described lack of time as a barrier to program engagement. One commented, “I feel like in Latinx culture, it is more like we’re working or studying or doing all this stuff, but there, in other cultures, it is very common that they don’t have a job and they just go to school…” [L1b].
Inclusive Programming Facilitators
Participants recommended several strategies to enhance group cohesion, including, skilled facilitation, validation of individual differences, fostering connection, defining appearance broadly, and diversity. Specifically, participants noted facilitators, “have to know what we’re talking about” regarding cultural differences [L2b]. Women emphasized the importance of leaders, “do[ing] some research” [B3e] regarding multicultural concerns so, “they’re familiar with [cultural considerations]” [L2b] and able to understand participants’ lived experiences. Participants also recommended facilitators foster safety and have strong group management skills. If harmful comments are made, “The facilitator has to…take control of the conversation” [B2f]. Moreover, they noted that leaders need to ensure that participants are, “sensitive about weight,” [W1b], and, “no one fat shames or skinny shames anyone” [W1e].
Participants also considered validation and respect of individual differences crucial to group cohesion. They indicated that participants in heterogeneous groups need to be, “sensitive to” individual differences [L2b]. Women suggested acknowledgement of diverse viewpoints so, “you’re not catering to one specific group” [B1b]. Moreover, they recommended facilitators intentionally promote connection, which they viewed as achievable regardless of cultural differences. “You just have to make everyone feel like there’s something in here that they can identify with…We’re all women…We’re all in college… just point out the things that are in common and not the things that we physically can see that aren’t in common” [B2f].
Women also identified the importance of both defining appearance broadly, and promoting body acceptance; (“teaching about things involving self-worth and acceptance” [B1a] might improve everyone’s appearance satisfaction). “[Programming] should be less about how our bodies should look, …and be more like appreciating your own body” [W1b]. Indeed, participants said they would, “feel more comfortable being a part of something that promoted wellness…rather than focus on how to avoid [EDs and obesity]” [W2d].
Women across groups thought programs with racially and ethnically diverse members increase awareness of the experiences of individuals different from oneself. “If you have diversity in the group then people would realize, oh…like anybody and everybody can deal with it” [B1a]. They further noted disadvantages of homogeneous groups, recalling that interactions with similar others can yield, “a lot of the same information” [B2c]. Conversely, connecting with diverse individuals can show, “…that people are going to be different than you, but you may relate to them” [L1c].
Manual Development
Following completion of the focus groups, the (Blinded) manual was developed. Focus group data informed modifications to the four-session, clinician-lead, DBI-based Body Project manual (Stice et al., n.d., Table 1). Attention was given to removing the emphasis on thinness, and instead, emphasizing beauty ideals generally, to represent pressures experienced by Black and Latinx women more accurately. Activities/role plays were revised to highlight overall appearance pressures, and incorporate more culturally relevant examples, including, “I just started wearing a waist trainer. It’s supposed to help me get that perfect hourglass shape!” Some examples regarding the thin ideal were retained to ensure content acknowledged the continued focus on this ideal in the media. However, more diverse appearance standards were highlighted throughout, and intersections among ideals were discussed.
Table 1
Recommendations for ED prevention
Theme | Recommendation |
Diverse beauty standards across groups | - Incorporate diverse appearance narratives - Address physical features influencing attractiveness beyond body shape and size (e.g., hair, skin tone) - Include information emphasizing appearance issues relevant to women of color (e.g., family influences, curvy ideal) |
Lack of acknowledgement of racialized beauty standards and cultural appropriation | - Address racialized aspects of beauty - Retain some discourse surrounding thinness - Discuss cultural appropriation |
Culturally-specific impacts of standards | - Target consequences of appearance discrepancies for women of color (e.g., microaggressions) - Reflect harmful consequences of beauty ideals pertinent to women of color - Address detrimental aspects of appearance ideals beyond thinness |
Harm of appearance-related comments | - Include education regarding consequences of weight-related talk and deterrence strategies |
Stigmatization of mental health | - Acknowledge stigma - Expand outreach and engagement within Black and Latinx communities. |
Limitations of available resources | - Address misconceptions (e.g., EDs only affect White women) - Note prevalence and presentations of EDs in women of color |
Facilitators and barriers to inclusive programming | - When possible, offer individuals options for either racially and ethnically homogenous or heterogenous groups. - skilled facilitation - validation of individual differences - fostering connection - defining appearance broadly (emphasize body acceptance over appearance) |
Modifications to the four-session Healthy Weight manual were informed by focus group data indicating a preference for positive framing and body acceptance (Stice et al., n.d.). For example, the definition of the, “healthy ideal” in Stice and colleagues’ Healthy Weight manual stated, “the healthy ideal is a reasonably slender body, but one that has muscles and fat as well. Each is natural and serves important functions.” As this explanation suggests that an ideal body exists, this definition was changed to that used in the two-session, peer-lead Body Project, which describes the healthy ideal as, “the way your unique body looks when you are doing the necessary things to appropriately maximize your physical health, mental health, and overall quality of life” (Becker et al., 2012). Additionally, explicit nutritional and activity guidelines were removed from the Healthy Weight manual based on research suggesting that the inclusion of dietary principles weakened intervention efficacy (Stice et al., 2012). Additional recommendations for facilitator training and supervision are reviewed in the following section.